CONTINUING EDUCATION Back to Basics: Surgical Attire and Cleanliness
1.1
LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14502 Session: #0001 Fee: Members $8.80, Nonmembers $17.60
Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Kimberly Retzlaff, managing editor, with consultation from Helen Starbuck Pashley, MA, RN, CNOR, clinical editor, and Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Retzlaff, Ms Starbuck Pashley, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
The CE contact hours for this article expire January 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to surgical attire and cleanliness.
Conflict of Interest Disclosures
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.10.013
138 j AORN Journal
January 2014 Vol 99 No 1
AORN, Inc, 2014
Back to Basics: Surgical Attire and Cleanliness 1.1 LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
www.aorn.org/CE
ABSTRACT A clean perioperative environment is beneficial for both patients and perioperative team members, and surgical attire is the foundation of cleanliness. Perioperative personnel should adhere to general hygiene and wear clean, facility-laundered surgical attire in the health care facility. Implementing a surgical attire policy can be challenging because attire is linked to personal preference and image. There are ways to achieve compliance with attire recommendations as well as to implement an attire policy. To help ensure success, perioperative nurses should be prepared to help educate other team members and participate in monitoring and compliance efforts. AORN J 99 (January 2014) 139-143. AORN, Inc, 2014. http://dx.doi.org/ 10.1016/j.aorn.2013.10.013 Key words: surgical attire, hygiene, cleanliness, surgical site infection.
J
oe is a circulator in a busy OR; he does not like to go out during the workweek but decided to attend his friend’s bachelor party one Thursday night even though he had work the next day. Joe stayed out a little longer than planned, and when his alarm went off the next morning, he slept right through it. When Joe finally woke up, he realized that he was going to be late for work and jumped out of bed, splashed water on his face, and ran for his scrubs. The only scrubs he could find were the ones he wore the day before, which he found crumpled on the floor, but he put them on and ran for the door. Before he made it to the door, he was greeted by his sweet, loving dog, that proceeded to jump up on him and demand to be let out. He gave the dog some attention, let him out, and then headed off to the OR for work (Figure 1). There are many things wrong with this scenario if surgical cleanliness is the goal.
SURGICAL ATTIRE AND CLEANLINESS Surgical attire is the foundation of cleanliness, although it is not the only part of this foundation. It is important for perioperative nurses to make sure they maintain good hygiene in general, wear appropriate surgical attire (ie, bouffant hair coverings; masks; eye protection; clean, freshly laundered surgical attire; cover jackets) and practice hand hygiene.1 Like most perioperative nurses, Joe cannot plan every aspect of his life, which is why there are processes in place to help ensure that surgical patients are provided a clean and hygienic environment in which to undergo their procedures. To protect patients from the Joes of the world, there are strict requirements for health care worker and environmental hygiene, such as facility or third-party laundering of scrub attire and requiring that personnel cover their hair. The importance of a hygienic environment has been a basic of nursing care since the nineteenth
http://dx.doi.org/10.1016/j.aorn.2013.10.013
AORN, Inc, 2014
January 2014
Vol 99 No 1
AORN Journal j 139
January 2014 Vol 99 No 1
Figure 1. To follow proper attire and cleanliness recommendations, perioperative personnel should a) wear clean attire and a cap that covers all of the hair; b) ensure that personal clothing is clean and completely covered by surgical attire; c) ensure that identification badges are clean; d) wear clean, closed-toed shoes; and e) wear clean surgical attire that is laundered in a health careeaccredited facility. What’s Wrong With This Picture? reprinted with permission from AORN, Inc, Denver, CO. Copyright ª 2014. All rights reserved.
century, and it is as important today as it was back then. A study by Brown et al2 emphasizes the importance of the basic health care concept of cleanliness and hygiene. Interestingly, the article showed that physicians were non-compliant more often than nurses during observations of basic hygiene practices. For example, physicians were more likely to wear scrubs contaminated with blood to other areas of the hospital, including the cafeteria. 140 j AORN Journal
SPRUCE In 2012, Wright et al3 reported three instances of postoperative Gordonia bronchialis sternal wound infections in cardiac surgery patients. When investigating the environment and the care providers, researchers determined that a nurse anesthetist who cared for all three patients and who had been experiencing forearm dermatitis was a carrier of G bronchialis. Additionally, her roommate tested positive for the bacteria. On further investigation to determine the source of the infections, the organism was traced to the washing machine in the health care worker’s home. Studies have shown that facility and third-party laundering are superior to home laundering for eliminating microorganisms.4,5 Despite this, many facilities still allow home laundering. Although there is very little evidence to demonstrate that the home environment contaminates scrubs with pathogens that can spread to patients, studies such as the one by Wright et al3 demonstrate that the environment does have an effect on organisms that can survive and potentially spread from human to human or human to surfaces. The AORN “Recommended practices for surgical attire”1 was updated in 2010. Since that time, many facilities have faced implementation challenges. For example, although bouffant hats are preferred to skull caps because they offer more complete hair coverage (Figure 2), surgical team members can be resistant to wearing them. Resistance seems to arise from personal preference and perceptions of image and the skull cap as a status symbol for surgeons. One reason it is so important that perioperative personnel cover all of their hair with bouffant hats rather than skull caps is that research shows that the scalp and hair harbor bacteria, the scalp can become colonized with microorganisms, and shedding skin and hair from the scalp can carry this bacteria. For example, one study showed that Staphylococcus aureus and Staphylococcus epidermidis adhered tightly to human hair and could not be removed with routine shampooing and therefore posed an infection risk to patients.6
BACK TO BASICS: SURGICAL ATTIRE AND CLEANLINESS
www.aornjournal.org
When skin shedding occurs, microorganisms that may be present on the skin squames also can be dispersed. A study by Noble and colleagues7 demonstrated this fact, and the researchers recommended that perioperative team members wear clothing that is tightly woven to cover exposed skin as a means to contain the shedding skin squames. They also noted that even non-pathogenic organisms can be detrimental to surgical patients undergoing total joint replacement.7
Figure 2. A bouffant hat should be worn to cover all of the hair, scalp, and ears to minimize skin and hair shedding and protect surgical patients from bacteria.
Another issue that frequently arises is staff members complying with wearing long-sleeved scrub jackets (Figure 3). The reason this practice is important is that research has shown that human beings disperse skin scales, or squames, into the air.7
HOW-TO GUIDE There are numerous ways to implement and enforce hygiene and attire recommendations in the health care setting, and these policies are often facility specific. However, there are methods that can be used to facilitate change and promote compliance with new policies. One plan for achieving compliance with surgical attire recommendations was outlined by Graling8 in 2013: n
n n
n n
n n
n n Figure 3. Surgical attire should cover all exposed skin, including wearing long-sleeved attire that goes down to the wrists.
n
Gather stakeholders (eg, nurses, surgeons, anesthesia professionals, housekeeping personnel, ancillary team members). Review the evidence in support of surgical attire practice recommendations. Create a policy for surgical attire that is separate from the facility’s infection control policy. Implement the surgical attire plan in phases, which may improve acceptance. Set the tone for change by having leaders and champions lead by example and coach staf members who do not comply with the new policies. Clearly communicate expectations to team members, including the policy start date. Have team members sign an acknowledgement that they have read the policy and understand the expectations. Have a plan for handling noncompliance. Measure continued adherence to the policy. Follow a quality improvement model to help implement changes, measure success, and improve effectiveness. AORN Journal j 141
SPRUCE
January 2014 Vol 99 No 1
BENEFITS A clean perioperative environment is beneficial for both patients and perioperative team members. Although there are no randomized controlled trials demonstrating that surgical attire has a direct effect on surgical site infections, there is a multitude of other types of data (eg, case studies, laboratory studies) that demonstrate the risk of infection to patients when they are exposed to the skin, mucous membranes, and hair of surgical team members.6,9 Additionally, case studies have shown that microorganisms can live on fabrics and plastics, which can then be transported home, potentially infecting the health care worker or his or her family members, pets, or others in the health care worker’s environment.10 Contamination from the home environment can then be returned to the OR and surgical patients when the employee wears homelaundered scrubs. Although it may appear cost effective to use home laundering, when the cost of surgical site infections and infections carried into the home that could result in illness and lost employee time are considered, it is not cost effective.11 Wearing hospital-laundered surgical attire affords protection from this risk for patients, health care personnel, their family members, and the community.
in monitoring and compliance efforts. Some ideas for improving the chance of successful implementation of a surgical attire policy include the following: n
Be ready to support the policy with evidence, regulatory requirements, and financial data. n Get support from members of the executive team, including the chief executive officer, chief nursing officer, chief operations officer, and chief financial officer. n Emphasize the importance of the policy with regard to patient safety. n Be aware of barriers to practice change, such as lack of awareness and knowledge, motivation, long-standing beliefs, and practicalities (eg, lack of adequate supply of scrub clothes, providing skull caps, allowing one group to dress differently than another). n Invite team members to discuss issues and brainstorm solutions. n Have interactive meetings with all team members; send out electronic as well as written materials. n Use other practical methods for ensuring compliance: n Allow cloth caps to be worn if they are completely covered by a bouffant hat. TIPS & TRICKS n Have enough long-sleeved jackets in a variThere are many strategies to help ensure successful ety of sizes. implementation and compliance with a surgical n Allow long-sleeved shirts to be worn under attire and cleanliness policy. To help ensure sucscrub tops, as long as scrub jackets comcess, perioperative nurses should be prepared pletely cover them. to help educate other team members and participate n Provide facility-laundered caps and longsleeved shirts. n Prohibit personnel Resources for Attire & Cleanliness from wearing skull caps altogether unn Braswell ML, Spruce L. Implementing AORN recommended less they are compractices for surgical attire. AORN J. 2012;95(1):122-137. pletely covered by n Spruce L. Perioperative attire: the importance of following the a bouffant hat. recommended practice. AORN, Inc. http://www.slideshare.net/ n If compliance is not aornsocialmedia/recommended-practices-for-surgical-attire. occurring, explore Accessed October 15, 2013 new products or
142 j AORN Journal
BACK TO BASICS: SURGICAL ATTIRE AND CLEANLINESS
n
partner with industry to create products that fit personnel needs. Recognize staff members who follow policy and are champions for patient safety.
WRAP-UP The health care environment is one that is rapidly changing; new and resistant pathogens seem to be appearing every day. Protecting patients and perioperative team members from infectious agents is a primary focus of the perioperative nurse. Cleanliness and hygiene are the foundation of providing a safe patient environment, and this begins with surgical attire. There are many challenges facing those who are implementing surgical attire and hygiene recommendations, from a lack of inventory of appropriate clothing to non-enforcement of the policy and resistance to change. Perhaps resistance occurs because there are no studies linking surgical attire to surgical site infections. There may never be sufficient evidence to support surgical attire practices, however, because it would be unethical to conduct a trial on surgical patients that allowed some to undergo procedures during which their health care providers did not wear scrubs, masks, or caps. Allowing any one person’s comfort, personal preference, or perception of status to take precedence over accepted safety practices sets the stage for an environment that does not put patient safety first. It is up to perioperative nurses to protect patients, themselves, and others from the risk of infection. It may be challenging to get everyone to adhere to the attire rules, but perioperative nurses are up to the challenge if they understand what is at stake.
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References 1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62. 2. Brown B, Crawford P, Nerlich B, Koteyko N. The habitus of hygiene: discourses of cleanliness and infection control in nursing work. Soc Sci Med. 2008;67(7):1047-1055. 3. Wright SN, Gerry JS, Busowski MT, et al. Gordonia bronchialis sternal wound infection in 3 patients following open heart surgery: intraoperative transmission from a healthcare worker. Infect Control Hosp Epidemiol. 2012;33(12):1238-1241. 4. Twomey CL, Beitz H, Johnson BJ. Bacterial contamination of surgical scrubs and laundering mechanism: infection control implications. Infection Control Today. Published October 19, 2009. www.infectioncontroltoday. com/articles/2009/10/bacterial-contamination-of-surgical -scrubs-and-la.aspx. Accessed October 24, 2013. 5. Nordstrom JA, Reynolds KA, Gerba CP. Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs. Am J Infect Control. 2012;40(6): 539-543. 6. Mase K, Hasegawa T, Horii T, et al. Firm adherence of Staphylococcus aureus and Staphylococcus epidermidis to human hair and effect of detergent treatment. Microbiol Immunol. 2000;44(8):653-656. 7. Noble WC, Habbema JD, van Furth R, Smith I, de Raay C. Quantitative studies on the dispersal of skin bacteria into the air. J Med Microbiol. 1976;9(1):53-61. 8. Graling P. Surgical attire compliance for safe patients and practitioners [Patient Safety First]. AORN J. 2013;97(4): 475-478. 9. Tammelin A, Domicel P, Hambraeus A, St ahle E. Dispersal of methicillin-resistant Staphylococcus epidermidis by staff in an operating suite for thoracic and cardiovascular surgery: relation to skin carriage and clothing. J Hosp Infect. 2000;44(2):119-126. 10. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and plastic. J Clin Microbiol. 2000;38(2):724-726. 11. Gerba CP. Application of quantitative risk assessment for formulating hygiene policy in the domestic setting. J Infect. 2001;43(1):92-98.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, is the director, Evidence-Based Perioperative Practice, AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Check back in March 2014 for the next “Back to Basics” topic: Speak Up.
AORN Journal j 143
EXAMINATION CONTINUING EDUCATION
Back to Basics: Surgical Attire and Cleanliness
1.1 www.aorn.org/CE
PURPOSE/GOAL To provide the learner with knowledge of best practices related to surgical attire and cleanliness.
OBJECTIVES 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
Multiple studies have shown that facility and third-party laundering are superior to home laundering for eliminating microorganisms. a. true b. false
2.
One reason that it is important for perioperative personnel to cover their hair with a bouffant hat rather than a skull cap is that 1. bouffant hats offer more complete hair coverage. 2. making all personnel wear the same hat improves teamwork. 3. research shows that the scalp and hair harbor bacteria. 4. they are more comfortable. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
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3.
Noble et al concluded from their research that a. only pathogenic organisms are harmful to surgical patients. b. perioperative team members should wear loose-fitting clothing to enable ease of movement. c. perioperative team members should wear clothing that is tightly woven. d. skin squames do not harbor microorganisms.
4.
Strategies that can be used to achieve compliance with surgical attire policies include 1. clearly communicating expectations of team members, including the policy start date. 2. creating a stand-alone attire policy separate from the facility’s infection control policy. 3. having team members sign an acknowledgment that they received and understand the policy.
AORN, Inc, 2014
CE EXAMINATION implementing the plan in phases to improve acceptance. 5. measuring continued adherence to the policy. a. 2 and 4 b. 1, 2, and 4 c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5 4.
5.
Strategies that can be used to successfully implement a surgical attire policy include 1. allowing personnel a period of time to continue with non-compliant behavior.
www.aornjournal.org
emphasizing the importance of the policy with regard to patient safety. 3. gathering leaders and managers to discuss issues and create solutions. 4. providing facility-laundered caps and longsleeved shirts. 5. supporting the plan with evidence, regulatory requirements, and financial data. a. 1 and 3 b. 2, 4, and 5 c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5 2.
AORN Journal j 145
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
Back to Basics: Surgical Attire and Cleanliness
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2. Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No
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1.1 www.aorn.org/CE
7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 1.1 continuing education contact hour (66-minute) program: _________________________________
AORN, Inc, 2014
1.1
LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14502 Session: #0001 Fee: Members $8.80, Nonmembers $17.60
Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Kimberly Retzlaff, managing editor, with consultation from Helen Starbuck Pashley, MA, RN, CNOR, clinical editor, and Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Retzlaff, Ms Starbuck Pashley, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
The CE contact hours for this article expire January 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to surgical attire and cleanliness.
Conflict of Interest Disclosures
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.10.013
138 j AORN Journal
January 2014 Vol 99 No 1
AORN, Inc, 2014
Back to Basics: Surgical Attire and Cleanliness 1.1 LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
www.aorn.org/CE
ABSTRACT A clean perioperative environment is beneficial for both patients and perioperative team members, and surgical attire is the foundation of cleanliness. Perioperative personnel should adhere to general hygiene and wear clean, facility-laundered surgical attire in the health care facility. Implementing a surgical attire policy can be challenging because attire is linked to personal preference and image. There are ways to achieve compliance with attire recommendations as well as to implement an attire policy. To help ensure success, perioperative nurses should be prepared to help educate other team members and participate in monitoring and compliance efforts. AORN J 99 (January 2014) 139-143. AORN, Inc, 2014. http://dx.doi.org/ 10.1016/j.aorn.2013.10.013 Key words: surgical attire, hygiene, cleanliness, surgical site infection.
J
oe is a circulator in a busy OR; he does not like to go out during the workweek but decided to attend his friend’s bachelor party one Thursday night even though he had work the next day. Joe stayed out a little longer than planned, and when his alarm went off the next morning, he slept right through it. When Joe finally woke up, he realized that he was going to be late for work and jumped out of bed, splashed water on his face, and ran for his scrubs. The only scrubs he could find were the ones he wore the day before, which he found crumpled on the floor, but he put them on and ran for the door. Before he made it to the door, he was greeted by his sweet, loving dog, that proceeded to jump up on him and demand to be let out. He gave the dog some attention, let him out, and then headed off to the OR for work (Figure 1). There are many things wrong with this scenario if surgical cleanliness is the goal.
SURGICAL ATTIRE AND CLEANLINESS Surgical attire is the foundation of cleanliness, although it is not the only part of this foundation. It is important for perioperative nurses to make sure they maintain good hygiene in general, wear appropriate surgical attire (ie, bouffant hair coverings; masks; eye protection; clean, freshly laundered surgical attire; cover jackets) and practice hand hygiene.1 Like most perioperative nurses, Joe cannot plan every aspect of his life, which is why there are processes in place to help ensure that surgical patients are provided a clean and hygienic environment in which to undergo their procedures. To protect patients from the Joes of the world, there are strict requirements for health care worker and environmental hygiene, such as facility or third-party laundering of scrub attire and requiring that personnel cover their hair. The importance of a hygienic environment has been a basic of nursing care since the nineteenth
http://dx.doi.org/10.1016/j.aorn.2013.10.013
AORN, Inc, 2014
January 2014
Vol 99 No 1
AORN Journal j 139
January 2014 Vol 99 No 1
Figure 1. To follow proper attire and cleanliness recommendations, perioperative personnel should a) wear clean attire and a cap that covers all of the hair; b) ensure that personal clothing is clean and completely covered by surgical attire; c) ensure that identification badges are clean; d) wear clean, closed-toed shoes; and e) wear clean surgical attire that is laundered in a health careeaccredited facility. What’s Wrong With This Picture? reprinted with permission from AORN, Inc, Denver, CO. Copyright ª 2014. All rights reserved.
century, and it is as important today as it was back then. A study by Brown et al2 emphasizes the importance of the basic health care concept of cleanliness and hygiene. Interestingly, the article showed that physicians were non-compliant more often than nurses during observations of basic hygiene practices. For example, physicians were more likely to wear scrubs contaminated with blood to other areas of the hospital, including the cafeteria. 140 j AORN Journal
SPRUCE In 2012, Wright et al3 reported three instances of postoperative Gordonia bronchialis sternal wound infections in cardiac surgery patients. When investigating the environment and the care providers, researchers determined that a nurse anesthetist who cared for all three patients and who had been experiencing forearm dermatitis was a carrier of G bronchialis. Additionally, her roommate tested positive for the bacteria. On further investigation to determine the source of the infections, the organism was traced to the washing machine in the health care worker’s home. Studies have shown that facility and third-party laundering are superior to home laundering for eliminating microorganisms.4,5 Despite this, many facilities still allow home laundering. Although there is very little evidence to demonstrate that the home environment contaminates scrubs with pathogens that can spread to patients, studies such as the one by Wright et al3 demonstrate that the environment does have an effect on organisms that can survive and potentially spread from human to human or human to surfaces. The AORN “Recommended practices for surgical attire”1 was updated in 2010. Since that time, many facilities have faced implementation challenges. For example, although bouffant hats are preferred to skull caps because they offer more complete hair coverage (Figure 2), surgical team members can be resistant to wearing them. Resistance seems to arise from personal preference and perceptions of image and the skull cap as a status symbol for surgeons. One reason it is so important that perioperative personnel cover all of their hair with bouffant hats rather than skull caps is that research shows that the scalp and hair harbor bacteria, the scalp can become colonized with microorganisms, and shedding skin and hair from the scalp can carry this bacteria. For example, one study showed that Staphylococcus aureus and Staphylococcus epidermidis adhered tightly to human hair and could not be removed with routine shampooing and therefore posed an infection risk to patients.6
BACK TO BASICS: SURGICAL ATTIRE AND CLEANLINESS
www.aornjournal.org
When skin shedding occurs, microorganisms that may be present on the skin squames also can be dispersed. A study by Noble and colleagues7 demonstrated this fact, and the researchers recommended that perioperative team members wear clothing that is tightly woven to cover exposed skin as a means to contain the shedding skin squames. They also noted that even non-pathogenic organisms can be detrimental to surgical patients undergoing total joint replacement.7
Figure 2. A bouffant hat should be worn to cover all of the hair, scalp, and ears to minimize skin and hair shedding and protect surgical patients from bacteria.
Another issue that frequently arises is staff members complying with wearing long-sleeved scrub jackets (Figure 3). The reason this practice is important is that research has shown that human beings disperse skin scales, or squames, into the air.7
HOW-TO GUIDE There are numerous ways to implement and enforce hygiene and attire recommendations in the health care setting, and these policies are often facility specific. However, there are methods that can be used to facilitate change and promote compliance with new policies. One plan for achieving compliance with surgical attire recommendations was outlined by Graling8 in 2013: n
n n
n n
n n
n n Figure 3. Surgical attire should cover all exposed skin, including wearing long-sleeved attire that goes down to the wrists.
n
Gather stakeholders (eg, nurses, surgeons, anesthesia professionals, housekeeping personnel, ancillary team members). Review the evidence in support of surgical attire practice recommendations. Create a policy for surgical attire that is separate from the facility’s infection control policy. Implement the surgical attire plan in phases, which may improve acceptance. Set the tone for change by having leaders and champions lead by example and coach staf members who do not comply with the new policies. Clearly communicate expectations to team members, including the policy start date. Have team members sign an acknowledgement that they have read the policy and understand the expectations. Have a plan for handling noncompliance. Measure continued adherence to the policy. Follow a quality improvement model to help implement changes, measure success, and improve effectiveness. AORN Journal j 141
SPRUCE
January 2014 Vol 99 No 1
BENEFITS A clean perioperative environment is beneficial for both patients and perioperative team members. Although there are no randomized controlled trials demonstrating that surgical attire has a direct effect on surgical site infections, there is a multitude of other types of data (eg, case studies, laboratory studies) that demonstrate the risk of infection to patients when they are exposed to the skin, mucous membranes, and hair of surgical team members.6,9 Additionally, case studies have shown that microorganisms can live on fabrics and plastics, which can then be transported home, potentially infecting the health care worker or his or her family members, pets, or others in the health care worker’s environment.10 Contamination from the home environment can then be returned to the OR and surgical patients when the employee wears homelaundered scrubs. Although it may appear cost effective to use home laundering, when the cost of surgical site infections and infections carried into the home that could result in illness and lost employee time are considered, it is not cost effective.11 Wearing hospital-laundered surgical attire affords protection from this risk for patients, health care personnel, their family members, and the community.
in monitoring and compliance efforts. Some ideas for improving the chance of successful implementation of a surgical attire policy include the following: n
Be ready to support the policy with evidence, regulatory requirements, and financial data. n Get support from members of the executive team, including the chief executive officer, chief nursing officer, chief operations officer, and chief financial officer. n Emphasize the importance of the policy with regard to patient safety. n Be aware of barriers to practice change, such as lack of awareness and knowledge, motivation, long-standing beliefs, and practicalities (eg, lack of adequate supply of scrub clothes, providing skull caps, allowing one group to dress differently than another). n Invite team members to discuss issues and brainstorm solutions. n Have interactive meetings with all team members; send out electronic as well as written materials. n Use other practical methods for ensuring compliance: n Allow cloth caps to be worn if they are completely covered by a bouffant hat. TIPS & TRICKS n Have enough long-sleeved jackets in a variThere are many strategies to help ensure successful ety of sizes. implementation and compliance with a surgical n Allow long-sleeved shirts to be worn under attire and cleanliness policy. To help ensure sucscrub tops, as long as scrub jackets comcess, perioperative nurses should be prepared pletely cover them. to help educate other team members and participate n Provide facility-laundered caps and longsleeved shirts. n Prohibit personnel Resources for Attire & Cleanliness from wearing skull caps altogether unn Braswell ML, Spruce L. Implementing AORN recommended less they are compractices for surgical attire. AORN J. 2012;95(1):122-137. pletely covered by n Spruce L. Perioperative attire: the importance of following the a bouffant hat. recommended practice. AORN, Inc. http://www.slideshare.net/ n If compliance is not aornsocialmedia/recommended-practices-for-surgical-attire. occurring, explore Accessed October 15, 2013 new products or
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partner with industry to create products that fit personnel needs. Recognize staff members who follow policy and are champions for patient safety.
WRAP-UP The health care environment is one that is rapidly changing; new and resistant pathogens seem to be appearing every day. Protecting patients and perioperative team members from infectious agents is a primary focus of the perioperative nurse. Cleanliness and hygiene are the foundation of providing a safe patient environment, and this begins with surgical attire. There are many challenges facing those who are implementing surgical attire and hygiene recommendations, from a lack of inventory of appropriate clothing to non-enforcement of the policy and resistance to change. Perhaps resistance occurs because there are no studies linking surgical attire to surgical site infections. There may never be sufficient evidence to support surgical attire practices, however, because it would be unethical to conduct a trial on surgical patients that allowed some to undergo procedures during which their health care providers did not wear scrubs, masks, or caps. Allowing any one person’s comfort, personal preference, or perception of status to take precedence over accepted safety practices sets the stage for an environment that does not put patient safety first. It is up to perioperative nurses to protect patients, themselves, and others from the risk of infection. It may be challenging to get everyone to adhere to the attire rules, but perioperative nurses are up to the challenge if they understand what is at stake.
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References 1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:51-62. 2. Brown B, Crawford P, Nerlich B, Koteyko N. The habitus of hygiene: discourses of cleanliness and infection control in nursing work. Soc Sci Med. 2008;67(7):1047-1055. 3. Wright SN, Gerry JS, Busowski MT, et al. Gordonia bronchialis sternal wound infection in 3 patients following open heart surgery: intraoperative transmission from a healthcare worker. Infect Control Hosp Epidemiol. 2012;33(12):1238-1241. 4. Twomey CL, Beitz H, Johnson BJ. Bacterial contamination of surgical scrubs and laundering mechanism: infection control implications. Infection Control Today. Published October 19, 2009. www.infectioncontroltoday. com/articles/2009/10/bacterial-contamination-of-surgical -scrubs-and-la.aspx. Accessed October 24, 2013. 5. Nordstrom JA, Reynolds KA, Gerba CP. Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs. Am J Infect Control. 2012;40(6): 539-543. 6. Mase K, Hasegawa T, Horii T, et al. Firm adherence of Staphylococcus aureus and Staphylococcus epidermidis to human hair and effect of detergent treatment. Microbiol Immunol. 2000;44(8):653-656. 7. Noble WC, Habbema JD, van Furth R, Smith I, de Raay C. Quantitative studies on the dispersal of skin bacteria into the air. J Med Microbiol. 1976;9(1):53-61. 8. Graling P. Surgical attire compliance for safe patients and practitioners [Patient Safety First]. AORN J. 2013;97(4): 475-478. 9. Tammelin A, Domicel P, Hambraeus A, St ahle E. Dispersal of methicillin-resistant Staphylococcus epidermidis by staff in an operating suite for thoracic and cardiovascular surgery: relation to skin carriage and clothing. J Hosp Infect. 2000;44(2):119-126. 10. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and plastic. J Clin Microbiol. 2000;38(2):724-726. 11. Gerba CP. Application of quantitative risk assessment for formulating hygiene policy in the domestic setting. J Infect. 2001;43(1):92-98.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, is the director, Evidence-Based Perioperative Practice, AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Check back in March 2014 for the next “Back to Basics” topic: Speak Up.
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EXAMINATION CONTINUING EDUCATION
Back to Basics: Surgical Attire and Cleanliness
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PURPOSE/GOAL To provide the learner with knowledge of best practices related to surgical attire and cleanliness.
OBJECTIVES 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
Multiple studies have shown that facility and third-party laundering are superior to home laundering for eliminating microorganisms. a. true b. false
2.
One reason that it is important for perioperative personnel to cover their hair with a bouffant hat rather than a skull cap is that 1. bouffant hats offer more complete hair coverage. 2. making all personnel wear the same hat improves teamwork. 3. research shows that the scalp and hair harbor bacteria. 4. they are more comfortable. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
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3.
Noble et al concluded from their research that a. only pathogenic organisms are harmful to surgical patients. b. perioperative team members should wear loose-fitting clothing to enable ease of movement. c. perioperative team members should wear clothing that is tightly woven. d. skin squames do not harbor microorganisms.
4.
Strategies that can be used to achieve compliance with surgical attire policies include 1. clearly communicating expectations of team members, including the policy start date. 2. creating a stand-alone attire policy separate from the facility’s infection control policy. 3. having team members sign an acknowledgment that they received and understand the policy.
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CE EXAMINATION implementing the plan in phases to improve acceptance. 5. measuring continued adherence to the policy. a. 2 and 4 b. 1, 2, and 4 c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5 4.
5.
Strategies that can be used to successfully implement a surgical attire policy include 1. allowing personnel a period of time to continue with non-compliant behavior.
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emphasizing the importance of the policy with regard to patient safety. 3. gathering leaders and managers to discuss issues and create solutions. 4. providing facility-laundered caps and longsleeved shirts. 5. supporting the plan with evidence, regulatory requirements, and financial data. a. 1 and 3 b. 2, 4, and 5 c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5 2.
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LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
Back to Basics: Surgical Attire and Cleanliness
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his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2. Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No
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7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 1.1 continuing education contact hour (66-minute) program: _________________________________
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